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Sir:

I would like to thank the authors of this article for their contribution to an area where there is a relative dearth of data.1 However, I believe the study methodology and results require some scrutiny.

The study included 443 patients with 775 breasts. The authors do not state the number of breasts operated on that had cancer. From the numbers presented, it would appear that the vast majority of cases were bilateral nipple-sparing mastectomies. Thus, the question arises of whether these bilateral cases were in fact cases of bilateral breast cancer or unilateral breast cancer with a symmetrization procedure on the normal side. This is an important consideration given the authors’ conclusion that nipple loss is primarily related to positive oncologic margins.

Furthermore, the data provided in the Results section with regard to the 51 nipple losses are unclear. These data could have been better presented in the format of a separate table providing a detailed breakdown of the various causes of nipple loss.

The authors go on to state that five surgeons performed the mastectomies in this series, with three performing 99 percent of them. First, two surgeons performed 1 percent of the operations, and I wonder whether inclusion of these surgeons’ data is worthwhile and in fact even valid. Second, of the three main surgeons, surgeon 2 appears to have both a lower rate of a positive nipple margin and a significantly better rate of nipple survival compared with his or her colleagues. It seems that surgeon 2’s outcomes make them an outlier in the normative distribution curve, and this may preclude inclusion of his or her data among the data from his or her colleagues. How this surgeon manages to obtain such good outcomes (as one would assume that a nipple survival rate of 0.6 percent is the result of a thicker mastectomy flap, although then the much lower rate of positive nipple margins flies in the face of this assumption) merits, in my view, a further independent study.

In the Discussion section, the authors present “odds” ratios that seem to imply that preoperative radiation therapy and periareolar incisions are both risk factors for nipple necrosis. However, no confidence interval is presented for either of these two figures. Furthermore, Table 1 provides a p value for preoperative radiation therapy that suggests that its effect is not significant. When presenting odd ratios, they must be followed by at least a confidence interval and/or a p value so that readers are able to make informed conclusions on the data presented.

It is clear that this was not an oncologic study; however, it would be useful to readers if in the future the authors were able to correlate oncologic grade of the tumor with recurrence of cancer in the nipple. Further research could include disease-free survival and absolute survival in addition to local recurrence rates. I look forward to further contributions from the authors on these topics that as yet have not been adequately investigated in terms of nipple-sparing mastectomy.

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David H. Song, M.D., M.B.A. is the President-elect of the American Society of Plastic Surgeons (ASPS). He is a consultant with BioMet, Emmi Solutions, LLC, a consortium-member providing senior debt for Brava, and consultant with and investor in HealthEngine.com. He receives author royalties from Elsevier. Scot Glasberg, M.D. is the President of the American Society of Plastic Surgeons (ASPS). He is a consultant with LifeCell Corp and Mentor Corp and an investor with Strathspey Crown. The authors have no sources of funding to report related to the writing or submission of this discussion.

The location and affiliation information should read as follows: Arlington Heights, Ill. From the American Society of Plastic Surgeons/Plastic Surgery Foundation.